Repeat Flow Diversion for Retreatment of Incompletely Occluded Large Complex Symptomatic Cerebral Aneurysms: A Retrospective Case Series

Ahmed Kashkoush; Mohamed E El-Abtah; Mark A Davison; Gabor Toth; Nina Moore; Mark Bain

doi:10.1227/ons.0000000000001056

Repeat Flow Diversion for Retreatment of Incompletely Occluded Large Complex Symptomatic Cerebral Aneurysms: A Retrospective Case Series

Oper Neurosurg (Hagerstown). 2024 Jan 22. doi: 10.1227/ons.0000000000001056. Online ahead of print.

Authors

Ahmed Kashkoush^{1

2}, Mohamed E El-Abtah³, Mark A Davison^{1

2}, Gabor Toth^{2

4}, Nina Moore^{1

2}, Mark Bain^{1

2}

Affiliations

¹ Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA.
² Cerebrovascular Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
³ Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.
⁴ Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA.

PMID: 38251895
DOI: 10.1227/ons.0000000000001056

Abstract

Background and objectives: Data regarding radiographic occlusion rates after repeat flow diversion after initial placement of a flow diverter (FD) in large intracranial aneurysms are limited. We report clinical and angiographic outcomes on 7 patients who required retreatment with overlapping FDs after initial flow diversion for large intracranial aneurysms.

Methods: We performed a retrospective review of a prospectively maintained database of cerebrovascular procedures performed at our institution from 2017 to 2021. We identified patients who underwent retreatment with overlapping FDs for large (>10 mm) cerebral aneurysms after initial flow diversion. At last angiographic follow-up, occlusion grade was evaluated using the O'Kelly-Marotta (OKM) grading scale.

Results: Seven patients (median age 57 years) with cerebral aneurysms requiring retreatment were identified. The most common aneurysm location was the ophthalmic internal carotid artery (n = 3) and basilar trunk (n = 3). There were 4 fusiform and 3 saccular aneurysms. The median aneurysm width was 18 mm; the median neck size for saccular aneurysms was 7 mm; and the median dome-to-neck ratio was 2.8. The median time to retreatment was 9 months, usually due to symptomatic mass effect. After retreatment, the median clinical follow-up was 36 months, MRI/magnetic resonance angiography follow-up was 15 months, and digital subtraction angiography follow-up was 14 months. Aneurysm occlusion at last angiographic follow-up was graded as OKM A (total filling, n = 1), B (subtotal filling, n = 2), C (early neck remnant, n = 3), and D (no filling, n = 0). All patients with symptomatic improvement were OKM C, whereas patients with worsened symptom burden were OKM A or B. Two patients required further open surgical management for definitive management of the aneurysm remnant.

Conclusion: Although most patients demonstrated a decrease in aneurysm remnant size, many had high-grade persistent filling (OKM grades A or B) in this subset of mostly large fusiform aneurysms. Larger studies with longer follow-up are warranted to optimize treatment strategies for atypical aneurysm remnants after repeat flow diversion.